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Surgery Spares Fertility

By Eileen A. Ellig

Denise Joost would like nothing more than to start a family.

That likelihood looked grim a few years ago when she was diagnosed with cervical cancer and told she would need a radical hysterectomy (removal of all the female reproductive organs) to treat the disease.

But as luck would have it, a clinical fellow rounding with her doctor that day mentioned he had heard of a procedure that could preserve her fertility.

After a radical surgical procedure to treat her cervical cancer, Denise Joost is now disease-free and ready to start a family with her husband, Chad.

Joost’s attention quickly turned to Charles Landen, M.D., now an assistant professor in MD Anderson’s Department of Gynecologic Oncology. “All of a sudden my focus shifted, and I wanted to know more.”

Landen was referring to a procedure called a radical trachelectomy, which is similar to a radical hysterectomy, except a woman’s uterus, or womb, is left intact.

Only about 500 such surgeries have been performed to date — most of them done outside the United States.

When Joost heard that MD Anderson was one of the few centers in the nation offering women this option, she welcomed the opportunity to discuss the procedure with Pedro Ramirez, M.D., associate professor in the Department of Gynecologic Oncology.

Ramirez has done more than 20 radical trachelectomies since 2005, after being trained by Daniel Dargent, a French surgeon who pioneered the procedure.

The possibility of maintaining her fertility while getting rid of the cancer seemed too good to be true, but was definitely something to consider, Joost says.

Newly engaged, she recalls telling her then fiancé, Chad, “If you don’t want to marry me because I might not be able to have children, I understand since that has always been part of our plan.”

His response to her was, “Your health is first and foremost, and I have no intention of spending the rest of my life with a baby and a memory of you.”

Buoyed by his love and support, Joost was ready to learn all she could about the radical trachelectomy.

A real page turner

With three pages of typewritten notes in hand, Joost joked to Ramirez, “I hope you didn’t schedule the standard 10-minute doctor visit because you’re going to run behind all day.”

She and Chad had a lot of questions.

Ramirez wasn’t surprised. “He was very receptive,” Joost says, “and clear that patients before me had declined to have the surgery.”

Pedro Ramirez, M.D., is offering women with cervical cancer a surgical option that not only treats their cancer, but also preserves their fertility.

Patients are told upfront that “this is a relatively novel approach and that we don’t know the true long-term side effects associated with it, although evidence suggests that the risk of recurrence and the overall survival is equivalent to having a radical hysterectomy,” Ramirez says. “Therefore, outcome is not compromised.”

Joost learned that during the surgery, the cervix (the lower part of the uterus that connects to the vagina), the parametria (tissue located adjacent to the cervix), the area lymph nodes and the upper 2 centimeters of the vagina are removed. The uterus remains, however, and is then reattached to the vagina.

Ramirez explains that since one of the primary functions of the cervix is to support a growing baby, a permanent suture, or cerclage, is placed where the cervix used to be “to assure there is no risk of losing the pregnancy.”

While a woman will most likely be able to conceive naturally, she’ll require a C-section at delivery because the tightly woven cerclage prevents a baby from passing through the vaginal canal, he says.

Women considering a radical trachelectomy often are concerned about the perceived likelihood of miscarrying. While a common fear, Ramirez says that the risk of first and second trimester pregnancy loss is comparable to the general population.

Conception rates following surgery are favorable as well, he says. Of the women who have tried to conceive, approximately 50 percent have gotten pregnant and 73% of them carried their pregnancy to term.

Although these positive outcomes make the radical trachelectomy an attractive option, the surgery isn’t for everyone.

“We’re very selective about who undergoes this procedure,” Ramirez says. “It’s been shown that there is a higher risk of recurrence or need for postoperative radiation therapy if women don’t meet the specified criteria.”

No evidence of the tumor extending into the upper cervical canal and no detection of metastases, or spread, to the lymph nodes.

The procedure also isn’t without risk.

Some women may experience irregular bleeding, stop menstruating and become infertile as a result of the surgery. Vascular and nerve damage, and injuries to the bladder, urethra and rectum also have been associated with the surgery — although these complications are similar to those seen with a radical hysterectomy and other abdominal surgeries.

A bit of soul-searching

For the thirty-something couple, information alone wasn’t enough to decide whether or not to have the radical trachelectomy.

During a radical trachelectomy, the cervix, the tissue and area lymph nodes surrounding the cervix, and the upper 2 centimeters of the vagina are removed. The uterus remains, however, and is then reattached to the vagina.

“We wanted to make sure we were doing it for the right reasons, which is that we wanted to have children, and that I really met all of the criteria,” Joost says.

The answer to both was “yes.”

They decided to go through with the surgery, knowing that Ramirez might have to do a radical hysterectomy after all if the cancer was more widespread than initially thought.

“We knew that could be necessary, so I gave him permission ahead of time to do what he needed to do,” Joost says. “I was prepared for that. My only request was that Chad be the one to tell me what happened when I came to.”

Fortunately, everything went according to plan, and just four months after the surgery, Joost and Chad were married.

“I was relieved with the choice I made,” Joost says. “And even if we never have children, I’ll never regret having this surgery.”

Now two years out, Joost remains cancer-free and is trying to conceive.

Ramirez feels she has a good chance. “He’s waiting for me to call and tell him that I’m pregnant any minute now,” Joost says. “But no pressure!”

Cervical Cancer Facts

When detected early, cancer often can be managed and treated successfully.

This is especially true for cervical cancer, a disease that is expected to strike more than 11,000 women this year.

When discovered and treated in its early stages, the survival rate is 92%, according to the American Cancer Society.

Since its debut in the 1950s, the Pap smear has been the tried-and-true way to screen for cervical cancer. Since then, it has significantly reduced the number of deaths related to the disease, says Pedro Ramirez, M.D., associate professor in MD Anderson’s Department of Gynecologic Oncology.

The Pap test can identify abnormal cells in the cervix that, if left unchecked, could lead to cancer, including those changes brought on by the human papillomavirus. HPV is a sexually transmitted disease.

Most often cervical cancer can be linked to HPV infection. In particular, two strains of the virus — HPV 16 and 18 — are highly associated with the disease, accounting for 70% of all cases. These, and two other types, which cause 90% of genital warts, are the target of a new vaccine that prevents the virus from taking root and causing cancer.

Approved by the U.S. Food and Drug Administration in 2006, Gardasil® is recommended for females ages 9 to 26 and is best administered before one becomes sexually active or is exposed to HPV, Ramirez says.

While women of all ages can develop cervical cancer at any time, Ramirez notes that those who have had sexual intercourse at an early age, who have multiple sexual partners and who smoke are more at risk.

It’s important, he stresses, that women continue to get routine Pap smears since the test can pick up early disease, even before a woman experiences any symptoms. Typically, there are no early warning signs indicating that something may be amiss.

If a woman, however, has any abnormal bleeding or discharge, bleeding after intercourse and/or pain, she should consult her physician.